Information was received indicating that when filling the smiths medical cadd cassette reservoir, the bag has been breaking in the cassette, leaking the medication.It was reported that a syringe attached at the end was used to add drug and it started to leak out of the cassette.No patient consequences were reported.No adverse effects were reported.
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Other, other text: once cassette was returned.Leak testing was performed and the unit was found to be leaking on the joint of the tube.The bag sealer machine id# bfm-2-1-001 was causing the weak seal condition on the joint of the tube with the bag, the generator of the equipment was identified.Procedure not followed: the two forms related to the procedures pm-1011 and pm-1026, for to register units with leak were not filling up, even that was identified the equipment malfunction, as well the method to test the units in both process was not followed as is required, forcing the equipment to release parts with potential leak condition.No corrective actions have been identified at this time; our investigation remains in progress.
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